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Manual helps agency sail through JCAHO survey
This is the sort of apocryphal tale that home care staff might share in the days of the dreaded anticipation of an accreditation survey.
A home care agency nurse was driving to a patient’s home. An accreditation surveyor accompanied her. The pair drove by a dead animal in the road. Later the surveyor cited the agency because the nurse failed to pick up the carcass. The agency’s outdated manual said that nurses on the road would pick up all road kill.
"This is just to show that what you have in your manual you better be able to say your agency follows," says Katherine France, RN, MN, executive director of the Visiting Nurses Association in New Orleans.
It’s because of that type of experience, which happened to an agency France once worked for, that she now recommends agencies write their own manuals. "I looked at different manuals put out by several organizations, such as policy and procedure manuals for clinical staff to follow, and none fit our agency," France says. "We started from scratch and developed our own manual."
Staff at the Visiting Nurses Association, which has 2,500 visits per month, spent a year working on the manual. (See sample page from manual, inserted in this issue.) The effort paid off. The agency underwent its first survey by the Oakbrook Terrace, IL-based Joint Commission on Accreditation for Healthcare Organizations in late summer 1998, and the agency received accreditation with commendation.
One key to the agency’s survey success was that managers made sure the staff knew the new manual inside-out by holding numerous inservices and regularly asking them questions, says Maria Des Bordes, RN, director of nursing. "We went through the manual — page by page, standard by standard — because the Joint Commission covers everything."
France and Des Bordes outlined the process the agency used to create the manual and prepare for the Joint Commission survey as follows:
1. Include Joint Commission and government regulations in manual.
Agencies should make sure their manuals contain all of the accrediting organization’s requirements, as well as Medicare, and state guidelines. France found that the most effective way to do this was to have staff read the Joint Commission manual, using it as the framework. After managers wrote the manual, it was reviewed by the agency’s quality assurance and education staff, as well as by Des Bordes and France.
"Nothing was printed until it was approved by all of these people," France says. Some agencies might choose to hire a consultant to help write the manual, although the New Orleans agency did not, she notes.
"We did hire a consultant to come in and do a mock survey. She went out with our staff and made a couple of recommendations," France says. "When she returned, she said, You will be accredited with commendation; you’re doing everything you need to do, so don’t change.’"
2. Give clinical staff some say over proposed requirements.
The proposed manual also had to be approved by the clinical staff, since these were the people who would be required to follow the rules.
A consultant or manager might suggest the agency include a guideline that seems like an important standard, although it’s unrealistic.
For instance, it could be a rule that the agency will call a patient twice before making a visit. However, employees perhaps have never made those two calls, and they may be unwilling to start the practice. In that scenario, France says, managers should leave that suggested guideline out of the manual. The Joint Commission will not be impressed that an agency has some very strict guidelines in its manual unless all employees follow those guidelines religiously, she notes.
"If the clinical staff says a requirement is impossible and they can’t do it, then don’t print it in the manual," France advises. "Don’t go into overkill."
Another example of an unrealistic guideline is requiring nurses to wash their nursing bags every night. "That’s not necessary," France says. "It has to be kept clean absolutely, but you don’t have to take it apart every night. . . . We asked for everyone’s point of view, and we saved a lot of money by doing the manual together."
Managers also drilled staff, by asking them questions that could be answered with the manual. "If you can’t locate things in the manual, then it looks like you’ve never opened it before, and it’s just sitting in a corner," Des Bordes says.
By the week of the survey, the staff knew the manual so well that if a surveyor had asked to see a particular policy in it, any employee could have flipped to that exact page, France says.
3. Make it easy for surveyors to find necessary details about the agency.
The New Orleans Visiting Nurses Association impressed the surveyor by giving her a 16-page booklet that included the agency’s mission statement, its history, its philosophy, and the board members’ names and phone numbers.
"We also gave her graphs of the outcomes of the goals we had set and our objectives for patient goals," France says. "If we said a stage three decubitus ulcer would heal in X amount of time, we showed her a graph of whether we were successful in that or not."
The booklet also listed the background of key personnel, including their years of service in home care. (See sample items from booklet, inserted in this issue.)
"We also gave the surveyor a case history of the patient she was going to visit, with a little background on the patient that she could read if she wanted to," France says. "We didn’t use names, only the patient’s initials." The surveyor said the background information made her job very easy, she adds.
However, this didn’t excuse staff from having to study and learn what they needed to about their cases. Managers made sure nurses knew every significant detail about their patients and about what the aides were doing for a particular case, Des Bordes says.
"The nurses’ notes had to make sense and stand on their own, with all orders dated correctly," Des Bordes adds. "We called physicians to make sure they were getting everything in on time, and we checked documentation to make sure it didn’t need to be corrected."
4. Post information that staff doesn’t need to memorize.
Visiting Nurses Association managers gathered the agency’s organizational chart, department goals, personnel information, and disaster plans and posted these guidelines in frames on the walls.
"I did that because I didn’t want anyone to rely on their memory if they got a little nervous," France says. "It was okay if a surveyor said, Tell me a goal for your department,’ and someone could say, Well they’re right here on the wall,’ and then read them off."
The surveyor was impressed with this, she adds.
The wall charts included details, such as what home care staff would do to assist patients during a disaster, according to whether the patient was a level one, level two, or level three risk. The level three pertains to patients who might need the greatest amount of assistance.
Another example might be if the surveyor asks an employee how many therapists the agency employs. All the employee has to say is, "We have all the therapists posted right there," France adds.
"We made it as easy as possible for the questions we thought she would ask," France says.
5. Challenge a survey citation when you have a good case.
"You can prove your case to the Joint Commission if they question you about something, and if you know your agency is right on a certain policy," France says.
The agency had one small problem pertaining to physician orders. Occasionally, a home care visit was missed, and the surveyor couldn’t find evidence of verbal physician orders acknowledging the missed visits. The surveyor said this was an error.
France disagreed. Louisiana home care rules allow agencies to skip obtaining a verbal order from the physician for a missed visit as long as the agency communicated the missed visit to the physician and documented that communication in the conference note. "You don’t have to get the physician to sign it," she adds. "You have to communicate it and document that you communicated it."
France proved the agency’s case by quickly calling the director of the state’s home care division and asking the director to sign a letter explaining the policy, which was just as she recalled.
"The surveyor would have cited us for that, so you shouldn’t be afraid to defend your case," France adds. "You need to be strong enough to say, I’m right, and I can prove it, and this is what I’m going to do.’"
• Maria Des Bordes, RN, Director of Nursing, Visiting Nurses Association Inc., 2475 Canal St., Suite 248, New Orleans, LA 70119. Telephone: (504) 822-1477.
• Katherine France, RN, MN, Executive Director, Visiting Nurses Association Inc., 2475 Canal St., Suite 248, New Orleans, LA 70119. Telephone: (504) 822-1477.